Prior authorization requirements cost the U.S. healthcare system an estimated $35 billion each year, and their overuse has triggered a backlash, stirring some policymakers into action. [MEDPAGE TODAY]

Whether these changes actually fix prior authorization for patients and clinicians is an open question. Meanwhile, stakeholders are weighing the risks versus benefits of artificial intelligence (AI) to streamline processes, according to a recent Health Affairs Insider report.

Prior authorization is a form of utilization management designed to gauge the appropriateness of certain medical and pharmacy services -- think elective surgeries, imaging tests, brand-name drugs, and biologics. However, the time and expense for physicians chasing approvals and the potential harm to patients leave many wondering whether these policies serve their intended purpose.

On the clinician side, practices complete about 39 prior authorization requests per physician per week, according to a 2024 American Medical Association survey. Ninety-three percent of physicians experienced delays in care while waiting for prior authorization approvals, 82% said prior authorization has sometimes led patients to abandon treatment, and 29% blamed prior authorization for delays that led to serious adverse events including hospitalizations and deaths.

Moreover, a 2023 KFF survey showed that about 16% of U.S. adults reported problems with prior authorization in the prior year.

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